Provider Demographics
NPI:1225624919
Name:GUARIONEX DECASTRO DMD PA
Entity Type:Organization
Organization Name:GUARIONEX DECASTRO DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GUARIONEX
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:501-663-3334
Mailing Address - Street 1:5917 W 12TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1600
Mailing Address - Country:US
Mailing Address - Phone:501-663-3334
Mailing Address - Fax:
Practice Address - Street 1:5917 W 12TH ST STE A
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1600
Practice Address - Country:US
Practice Address - Phone:501-663-3334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1750499547Medicaid